Consolidated Project Information Project 3.a.i Primary ... 3.a.i...Integration of behavioral health and primary care services can serve 1) to identify behavioral health diagnoses early,

Project 3.a.i For more information please contact Laura Siddons, Project Manager [email protected] 631-638-1349 Version 5 – 10.25.15

Consolidated Project Information Project 3.a.i Primary & Behavioral Health Integrated Care Program


3.a.i Integration of Primary Care and Behavioral Health Services

3.a.i Project Objective & Requirements Integration of behavioral health and primary care services can serve 1) to identify behavioral health diagnoses early, allowing rapid treatment, 2) to ensure

treatments for medical and behavioral health conditions are compatible and do not cause adverse effects, and 3) to de-stigmatize treatment for behavioral

health diagnoses. Care for all conditions delivered under one roof by known healthcare providers is the goal of this project.

The project goal can be achieved by 1) integration of behavioral health specialists into primary care clinics using the collaborative care model and supporting

the PCMH model, or 2) integration of primary care services into established behavioral health sites such as clinics and Crisis Centers. When onsite

coordination is not possible, then in model 3) behavioral health specialists can be incorporated into primary care coordination teams (see project IMPACT

described below).

The project must clearly demonstrate the following project requirements:

A. PCMH Service Site:

1. Co-locate behavioral health services at primary care practice sites. All participating primary care providers must meet 2014 NCQA level 3 PCMH or

Advance Primary Care Model standards by Demonstration Year (DY) 3.

2. Develop collaborative evidence-based standards of care including medication management and care engagement process.

3. Conduct preventive care screenings, including behavioral health screenings (PHQ-9, SBIRT) implemented for all patients to identify unmet needs.

4. Use EHRs or other technical platforms to track all patients engaged in this project.

B. Behavioral Health Service Site:

1. Co-locate primary care services at behavioral health sites.

2. Develop collaborative evidence-based standards of care including medication management and care engagement process.

3. Conduct preventive care screenings, including behavioral health screenings (PHQ-9, SBIRT) implemented for all patients to identify unmet needs.


C. IMPACT: This is an integration project based on the Improving Mood - Providing Access to Collaborative Treatment (IMPACT) model. IMPACT Model

requirements include:


1. Implement IMPACT Model at Primary Care Sites.

2. Utilize IMPACT Model collaborative care standards, including developing coordinated evidence-based care standards and policies and procedures

for care engagement.

3. Employ a trained Depression Care Manager meeting requirements of the IMPACT model.

4. Designate a Psychiatrist meeting requirements of the IMPACT Model.

5. Measure outcomes as required in the IMPACT Model.

6. Provide "stepped care” as required by the IMPACT Model.


Model 1: Embedding a Behavioral Health Specialist in Primary Care

Actively Engaged Definition: The total number of patients receiving appropriate preventive care screenings that include mental health/substance abuse.

Clarifying Information:

The PPS is expected to utilize the preventive care screening based on nationally-accepted best practices determined to be age-appropriate.

Any staffer working at a PCMH/APCM Service Site who is qualified to perform a preventive care screening can do so. However, preventive care screenings conducted with a patient via telepsychiatry alone will not count within this active engagement definition.

Appropriate screenings would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical record.

The expectation of a co-located primary care-behavioral health site is that there is a licensed behavioral health provider on site engaged in the practice. Model 2:

Actively Engaged Definition: The total number of patients receiving primary care services at a participating mental health or substance abuse site.

Clarifying Information:

Primary Care Services are defined as preventive care screenings billed through Current Procedural Terminology (CPT) codes.

The mental health and substance abuse sites have to be partners in the Network Tool in order to count

Any staffer working at a Behavioral Health Site who is qualified to perform a preventive care screening as required within the project can do so.


The only types of “primary care providers” that may be utilized to provide primary care services within the BH site are participating PCPs, NPs, and physician assistants working closely with a PCP.

Model 3: IMPACT model

Actively Engaged Definition: The total number of patients screened using the PHQ-2 or 9/SBIRT. Clarifying Information:

Patients for this project will only count as actively engaged if they receive either the PHQ-2 or 9 or SBIRT screenings.


All five principles of the IMPACT model must be in place for a site to count.

Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so.


DOMAIN 1 Project Requirements

Project System Changes (Green): Based upon the work plan section in Attachment I, NY DSRIP Program Funding and Mechanics Protocol, no more than the

first two years will be utilized to implement major system changes related to the project. Example project requirements that fall into this time period cohort

include: training for care coordinators, developing systematic approaches like clinical protocols, the identification of key project personnel, performing

population health management activities, or using EHRs or other technical platforms to track patients engaged in the project.

Project Requirements with Specific Time Periods (Pink): A number of project requirements include prescribed end dates for achievement. Example project

requirements include: safety net providers actively sharing medical records with RHIO/SHIN-NY by the end of DY 3 or PCPs achieving Level 3 PCMH

certification by the end of DY 3.

Project Requirements Tied to PPS Speed and Scale Commitments (Yellow): The due dates for these project requirements are at the discretion of the PPS and

should be consistent with commitments each PPS made in the speed and scale sections of the submitted project application. Project requirements within

this time period include components like implementing open access scheduling in all PCP practices, deploying a provider notification/secure messaging

system, or converting outdated or unneeded hospital capacity into needed community-based services.

Project-Unit Level Reporting - These are Domain 1 requirement metrics/deliverables which will be reported by the PPS lead at the project-wide level

demonstrating the PPS’ overall project performance and success. These are requirements not specific to individual provider but rather are requirements

that must be organized and administered by the PPS lead through the PPS’ participating providers and partners. Some of these requirements include

performing population health management activities, monthly meetings with MCOs, establishing partnerships between primary care providers and

participating Health Homes, and developing materials meeting the cultural and linguistic needs of the population.

Provider-Unit Level Reporting - These are Domain 1 requirement metrics/deliverables for which performance and success must be demonstrated at the

provider level. Some of these requirements include PCPs meeting 2014 NCQA Level 3 PCMH standards, EHR meeting RHIO HIE and SHIN-NY requirements or

implementing open access scheduling in PCP practices.


Domain 1 Requirements

Project Domain Clinical Improvement Projects (Domain 3)

3.a.i (Model 1)

Integration of primary care and behavioral health services

Project ID

Project Title

Index Score = 39

Definition of Actively Engaged

The total number of patients engaged in each of the three models in this project, including: A. PCMH/APC

Service Site: Number of patients receiving appropriate preventive care screenings that include mental

health/SA. B. Behavioral Health Site: Number of patients receiving primary care services at a participating

mental health or substance abuse site. C. IMPACT: Number of patients screened (PHQ-2 or 9 / SBIRT).

Project Requirement Metric/Deliverable Data Source(s) Unit Level

1

Co-locate behavioral health services at

primary care practice sites. All participating

primary care practices must meet 2014 NCQA

level 3 PCMH or Advance Primary Care Model

standards by DY 3.

All practices meet NCQA 2014 Level 3 PCMH

and/or APCM standards by the end of DY3.

List of participating NCQA-certified and/or

APC-approved physicians/practioners (APC

Model requirements as determined by NY

SHIP); Certification documentation

Provider

(PCP)

Behavioral health services are co-located

within PCMH/APC practices and are available.

List of practitioners and licensure performing

services at PCMH and/or APCM sites;

Behavioral health practice schedules

Provider

(BH)

2

Develop collaborative evidence-based

standards of care including medication

management and care engagement process.

Regularly scheduled formal meetings are held

to develop collaborative care practices.

Meeting schedule; Meeting agenda; Meeting

minutes; List of attendees

Project

Coordinated evidence-based care protocols

are in place, including medication

management and care engagement processes.

Evidence-based practice guidelines;

Implementation plan; Policies and procedures

regarding frequency of updates to guidelines

and protocols

Project



3.a.i (Model 1)


Project ID

Project Title

Index Score = 39







3

Conduct preventive care screenings, including

behavioral health screenings (PHQ-2 or 9 for

those screening positive, SBIRT) implemented

for all patients to identify unmet needs.

Policies and procedures are in place to

facilitate and document completion of

screenings.

Screening policies and procedures

Project

Screenings are documented in Electronic

Health Record.

Screenshots or other evidence of notifications

of patient identification and screening alerts;

EHR Vendor documentation

Project

At least 90% of patients receive screenings at

the established project sites (Screenings are

defined as industry standard questionnaires

such as PHQ-2 or 9 for those screening

positive, SBIRT).

Roster of identified patients; Number of

screenings completed

Project

Positive screenings result in "warm transfer"

to behavioral health provider as measured by

documentation in Electronic Health Record.

Sample EHR demonstrating that warm

transfers have occurred

Provider

(PCP)



3.a.i (Model 1)


Project ID

Project Title

Index Score = 39







4

Use EHRs or other technical platforms to

track all patients engaged in this project.

EHR demonstrates integration of medical and

behavioral health record within individual

patient records.

Sample EHR demonstrating both medical and

behavioral health Project Requirements

Project

PPS identifies targeted patients and is able to

track actively engaged patients for project

milestone reporting.

Sample data collection and tracking system;

EHR completeness reports (necessary data

fields are populated in order to track project

implementation and progress)

Project

Project 3.a.i For more information please contact Laura Siddons, Project Manager [email protected] 631-638-1349


3.a.i (Model 2)

Integration of primary care and behavioral

Project ID

Project Title

Index Score = 39


The total number of patients engaged in each of the three models in this project, including: A.

PCMH/APC Service Site: Number of patients receiving appropriate preventive care screenings that include

mental health/SA. B. Behavioral Health Site: Number of patients receiving primary care services

at a participating mental health or substance abuse site. C. IMPACT: Number of patients screened (PHQ-2

or 9 / SBIRT).


1

Co-locate primary care services at behavioral

health sites.

PPS has achieved NCQA 2014 Level 3 PCMH or

Advanced Primary Care Model Practices by

the end of DY3.

List of participating NCQA-certified and/or

APC-approved physicians/practioners (APC

Model requirements as determined by NY

SHIP); Certification documentation

Provider

(PCP)

Primary care services are co-located within

behavioral Health practices and are available.

List of practitioners and licensure

performing services at behavioral health

site; behavioral health practice schedules.

Provider

(PCP, BH)

2

Develop collaborative evidence-based

standards of care including medication


Regularly scheduled formal meetings are held

to develop collaborative care practices.

Meeting schedule; Meeting agenda;

Meeting minutes; List of attendees

Project


are in place, including a medication


Documentation of evidence-based practice

guidelines; Implementation plan; Policies

and procedures regarding frequency of

updates to evidence-based practice

documentation

Project



3.a.i (Model 2)


Project ID

Project Title

Index Score = 39






or 9 / SBIRT).


3

Conduct preventive care screenings, including

behavioral health screenings (PHQ-2 or 9 for

those screening positive, SBIRT) implemented

for all patients to identify unmet needs.

Screenings are conducted for all patients.

Process workflows and operational protocols

are in place to implement and document

screenings.

Screening protocols included in policies and

procedures; Log demonstrating the number

of screenings completed

Project

Screenings are documented in Electronic

Health Record.

Screenshots or other evidence of

notifications of patient identification and

screening alerts; EHR Vendor

documentation

Project





positive, SBIRT).

Screenings documented in EHR

Project

Positive screenings result in "warm transfer"

to behavioral health provider as measured by

documentation in Electronic Health Record.

Sample EHR demonstrating that warm

transfers have occurred

Provider

(PCP)



3.a.i (Model 2)


Project ID

Project Title

Index Score = 39






or 9 / SBIRT).


4

Use EHRs or other technical platforms to

track all patients engaged in this project.



patient records.

Sample EHR demonstrating both medical

and behavioral health Project Requirements

Project PPS identifies targeted patients and is able to





fields are populated in order to track

project implementation and progress)



3.a.i (Model 3)


Project ID

Project Title

Index Score = 39




mental health/SA. B. Behavioral Health Site: Number of patients receiving primary care services at a

participating mental health or substance abuse site. C. IMPACT: Number of patients screened (PHQ-2 or 9

/ SBIRT).


1

Implement IMPACT Model at Primary Care

Sites.

PPS has implemented IMPACT Model at

Primary Care Sites.

Quarterly report narrative demonstrating

successful implementation of project

requirements

Provider

(PCP

Practices)

2

Utilize IMPACT Model collaborative care

standards, including developing coordinated

evidence-based care standards and policies

and procedures for care engagement.


are in place, including a medication

management and care engagement process

to facilitate collaboration between primary

care physician and care manager.


guidelines; Implementation plan; Policies

and procedures regarding frequency of

updates to evidence-based practice

documentation

Project

Policies and procedures include process for

consulting with Psychiatrist.


guidelines

Project



3.a.i (Model 3)


Project ID

Project Title

Index Score = 39






/ SBIRT).


3

Employ a trained Depression Care Manager

meeting requirements of the IMPACT model.

PPS identifies qualified Depression Care

Manager (can be a nurse, social worker, or

psychologist) as identified in Electronic Health

Records.

Identification of Depression Care Manager

via Electronic Health Records

Project

Depression care manager meets

requirements of IMPACT model, including

coaching patients in behavioral activation,

offering course in counseling, monitoring

depression symptoms for treatment

response, and completing a relapse

prevention plan.

Evidence of IMPACT model training and

implementation; Sample EHR demonstrating

relapse prevention plans, patient coaching,

and other IMPACT interventions

Project

4

Designate a Psychiatrist meeting

requirements of the IMPACT Model.

All IMPACT participants in PPS have a

designated Psychiatrist.

Register of IMPACT participants and

designated psychiatrist; Policies and

procedures in place to follow up with care

of patients; Electronic Health Record

identifying Psychiatrist for eligible patients

Project



3.a.i (Model 3)


Project ID

Project Title

Index Score = 39






/ SBIRT).


5

Measure outcomes as required in the IMPACT

Model.





positive, SBIRT).

Roster of screened patients

Project

6

Provide "stepped care” as required by the

IMPACT Model.

In alignment with the IMPACT model,

treatment is adjusted based on evidence-

based algorithm that includes evaluation of

patient after 10-12 weeks after start of

treatment plan.


guidelines for stepped care; Implementation

plan

Project

7

Use EHRs or other technical platforms to track

all patients engaged in this project.



patient records.

Sample EHR demonstrating both medical

and behavioral health Project Requirements

Project

PPS identifies targeted patients and is able to





fields are populated in order to track project

implementation and progress)

Project

April 2, 2015: Demonstration Year 1

± A lower rate is desirable. * High Performance Eligible measure # Statewide measure ^ Performance Goal is a system default and may be changed following Measurement Year 1 results.

24

3.a.i Domain 3 Clinical Improvement Metrics

Domain 3 - Clinical Improvement Projects

Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) ±

3M

NA

3.a.i – 3.a.iv

Number of preventable emergency visits as defined by revenue and CPT codes

Number of people with a BH diagnosis (excludes those born during the measurement year) as of June 30 of measurement year

0.0^ per 100 Medicaid enrollees

with Behavioral

Health Qualifying

Service *High Perf Elig

1 if annual improvement target or performance goal met or exceeded

NYS DOH

P4P

P4P

Antidepressant Medication Management – Effective Acute Phase Treatment

HEDIS 2015

0105

3.a.i – 3.a.iv

Number of people who remained on antidepressant medication during the

Number of people 18 and older who were diagnosed with depression and treated with an

60.0%

*High Perf Elig

0.5 if annual improvement target or performance

NYS DOH

P4P

P4P



25

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP): MEASURE SPECIFICATION AND REPORTING MANUAL

Measure Name

Specification Version

NQF #

Projects Associated with Measure

Numerator Description

Denominator Description

Pe

rfo

rman

ce G

oa

l

*Hig

h P

erf

orm

ance

elig

ible

#S

tate

wid

e m

eas

ure

Achievement Value

Re

po

rtin

g

Re

spo

nsi

bili

ty

Pay

me

nt:

DY

2 a

nd

3

Pay

me

nt:

DY

4 a

nd

5

entire 12-week acute treatment phase

antidepressant medication

goal met or exceeded

Antidepressant Medication Management – Effective Continuation Phase Treatment

HEDIS 2015

0105

3.a.i – 3.a.iv

Number of people who remained on antidepressant medication for at least six months

Number of people 18 and older who were diagnosed with depression and treated with an antidepressant medication

43.5%

*High Perf Elig

0.5 if annual improvement target or performance goal met or exceeded

NYS DOH

P4P

P4P

Diabetes Monitoring for People with Diabetes and Schizophrenia

HEDIS 2015

1934

3.a.i – 3.a.iv

Number of people who had both an LDL-C test and an HbA1c test during the measurement year

Number of people, ages 18 to 64 years, with schizophrenia and diabetes

89.8% *High Perf Elig


NYS DOH

P4P

P4P

Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication

HEDIS 2015

1932

3.a.i – 3.a.iv

Number of people who had a diabetes screening test during the measurement year

Number of people, ages 18 to 64 years, with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication

89.0%


NYS DOH

P4P

P4P

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia

HEDIS 2015

1933

3.a.i – 3.a.iv

Number of people who had an LDL-C test during the measurement year

Number of people, ages 18 to 64 years, with schizophrenia and cardiovascular disease

92.2% (health

plan data) *High Perf Elig


NYS DOH

P4P

P4P



26


Measure Name


NQF #




Pe

rfo

rman

ce G

oa

l

*Hig

h P

erf

orm

ance

elig

ible

#S

tate

wid

e m

eas

ure

Achievement Value

Re

po

rtin

g

Re

spo

nsi

bili

ty

Pay

me

nt:

DY

2 a

nd

3

Pay

me

nt:

DY

4 a

nd

5

Follow-up care for Children Prescribed ADHD Medications – Initiation Phase

HEDIS 2015

0108

3.a.i – 3.a.iv

Number of children who had one follow-up visit with a practitioner within the 30 days after starting the medication

Number of children, ages 6 to 12 years, who were newly prescribed ADHD medication

72.3%


NYS DOH

P4R

P4P

Follow-up care for Children Prescribed ADHD Medications – Continuation Phase

HEDIS 2015

0108

3.a.i – 3.a.iv

Number of children who, in addition to the visit in the Initiation Phase, had at least 2 follow-up visits in the 9- month period after the initiation phase ended

ages 6 to 12 years, who were newly prescribed ADHD medication and remained on the medication for 7 months

78.7% (health plan data)


NYS DOH

P4R

P4P

Follow-up after hospitalization for Mental Illness – within 7 days

HEDIS 2015

0576

3.a.i – 3.a.iv

Number of discharges where the patient was seen on an ambulatory basis or who was in intermediate treatment with a mental health provider within 7 days of discharge

Number of discharges between the start of the measurement period to 30 days before the end of the measurement period for patients ages 6 years and older, who were hospitalized for treatment of selected mental health disorders

74.2%

*High Perf Elig


NYS DOH

P4P

P4P

Follow-up after hospitalization for Mental Illness – within 30 days

HEDIS 2015

0576

3.a.i – 3.a.iv

Number of discharges where the patient was seen on an ambulatory

Number of discharges between the start of the measurement

88.2% *High Perf Elig

0.5 if annual improvement target or

NYS DOH

P4P

P4P



27


Measure Name


NQF #




Pe

rfo

rman

ce G

oa

l

*Hig

h P

erf

orm

ance

elig

ible

#S

tate

wid

e m

eas

ure

Achievement Value

Re

po

rtin

g

Re

spo

nsi

bili

ty

Pay

me

nt:

DY

2 a

nd

3

Pay

me

nt:

DY

4 a

nd

5

basis or who was in intermediate treatment with a mental health provider within 30 days of discharge

period to 30 days before the end of the measurement period for patients ages 6 years and older, who were hospitalized for treatment of selected mental health disorders

performance goal met or exceeded

Screening for Clinical Depression and follow-up

0418

3.a.i – 3.a.iv

Number of people screened for clinical depression using a standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen

Number of people with a qualifying outpatient visit who are age 18 and older

100%^


PPS and NYS DOH

P4R

P4P

Adherence to Antipsychotic Medications for People with Schizophrenia

HEDIS 2015

1879

3.a.i – 3.a.iv

Number of people who remained on an antipsychotic medication for at least 80% of their treatment period

Number of people, ages 19 to 64 years, with schizophrenia who were dispensed at least 2 antipsychotic medications during the measurement year

76.5%


NYS

DOH

P4P

P4P



Measure Name


NQF #




Pe

rfo

rman

ce G

oa

l

*Hig

h P

erf

orm

ance

elig

ible

#S

tate

wid

e m

eas

ure

Achievement Value

Re

po

rtin

g

Re

spo

nsi

bili

ty

Pay

me

nt:

DY

2 a

nd

3

Pay

me

nt:

DY

4 a

nd

5

Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days)

HEDIS 2015

0004

3.a.i – 3.a.iv

Number of people who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the index episode

Number of people age 13 and older with a new episode of alcohol or other drug (AOD) dependence

86.0%


NYS

DOH

P4P

P4P

Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days)

HEDIS 2015

0004

3.a.i – 3.a.iv

Number of people who initiated treatment AND who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit

Number of people age 13 and older with a new episode of alcohol or other drug (AOD) dependence

31.4%


NYS

DOH

P4P

P4P


3.a.i Active Engagement Definition The active engagement definition for project 3.a.i is the total of number of patients engaged per each of the three models in this project,

including:

A. PCMH Service Site: Number of patients screened (PHQ-2 / PHQ-9 / SBIRT)

B. Behavioral Health Site: Number of patients receiving primary care services at a participating mental health or substance abuse site.

C. IMPACT: Number of patients screened (PHQ-2 / PHQ-9 / SBIRT)

Project # of

Actively

Engaged

Attributed

Population

% of

Attributed

Definition of Actively Engaged Counting

Method

3.a.i 45,059 148,118 30% 1) PHQ/SBIRT screening at PCMH site

2) Primary care services at BH site

3) PHQ/SBIRT screening at IMPACT site

3

The purpose of counting methods is to estimate the number of patients that will be impacted by a particular project. This feeds the patient scale

portion of the application.

Each counting method should be used in conjunction with the definition of “actively engaged” patients for that project.

Summary of counting method 3:

Counted within a DSRIP year; resets each year


Patients are to be counted only once

So long as “at least” one encounter with the patient resulted in A.E. definition being met, it counts towards total

e.g., if a patient visits the PCP 5 times a year but get a1C tested just one of those 5 times, she is actively engaged

3.a.i Speed and Scale Submission Scale is a measure of the magnitude of providers in the project and the volume of patients affected. Speed is a measure of how quickly project

requirements are executed and how quickly patient impact occur. Speed and Scale represent 80% of the points for each project application –

and therefore, most significantly impact initial valuation.

Project Implementation Speed for Project 3.a.i

Project DY 0 (2014) DY 1 (2015) DY 2 (2016) DY 3 (2017) DY 4 (2018)

Q1-2 Q3-4 Q1-2 Q3-4 Q1-2 Q3-4 Q1-2 Q3-4 Q1-2 Q3-4

3.a.i X

Patient Engagement Speed for Project 3.a.i

Patient Engagement Speed

DY0 DY1 DY2 DY3 DY 4

(Baseline)

Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4

Number of Actively Engaged Patients

0 0 2245 6785 8995 22489 17991 33734 22489 45059

Expected # of Actively Engaged Patients

45059 45059 45059 45059 45059 45059 45059 45059 45059 45059


Rationale for Project 3.a.i

The rationale related to project 3.a.i implementation speed is as follows:

• PCMH Level 3 certification by DY3 is a project requirement so 100% is achieved at end of DY3 to give practices maximum amount of time

to achieve

The rationale related to project 3.a.i patient engagement speed is as follows:

• The total of number of patients engaged per each of the three models in this project, including:

A. PCMH Service Site: Number of patients receiving appropriate preventive care screenings that include mental health/SU.

B. Behavioral Health Site: Number of patients receiving primary care services at a participating mental health or substance abuse

site.

C. IMPACT: Number of patients screened (PHQ-2 / PHQ-9 / SBIRT)

• Patients are counted as those who meet the criteria over a 1-year period. Duplicate counts of patients are not allowed. The count is not

additive across DSRIP years.


The patient scale rationale is calculated as detailed below.

References

Please see pages 47-54 in the Suffolk Care Collaborative DOH Application for additional project related information.

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_applications/docs/stony_brook_university_hospital/stony_brook_

project_plan.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_applications/docs/stony_brook_university_hospital/stony_brook_project_plan.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_applications/docs/stony_brook_university_hospital/stony_brook_project_plan.pdf

Documents

Consolidated Project Information Project 3.a.i Primary ... 3.a.i...Integration of behavioral health and primary care services can serve 1) to identify behavioral health diagnoses early,